Vol 1 | Issue 2 | Oct-Dec 2015 | page: 3-4 | D Handy Eone[1], J E Bayiha[1], J R Nyekel[1], B Ngo Nonga[2], J Bahebeck[1].
Authors : D Handy Eone[1], J E Bayiha[1], J R Nyekel[1], B Ngo Nonga[2], J Bahebeck[1].
[1] Hôpital Central de Yaoundé
[2] University Hospital Center Yaoundé
Address of Correspondence
Dr. D Handy Eone
Orthopaedic surgeon
Hôpital Central de Yaoundé
E-mail : dhandyeone@yahoo.fr
Abstract
Introduction: Unreduced hip dislocation for many weeks constitutes a severe traumatic lesion. Arthroplasty is indicated to help solve the complications which are related to the evolutions of such hips. However, muscular retractions and the difficulty in finding and working in the paleo-acetabulum make this procedure difficult. The objective of this work is to report a case of non-cemented total hip arthroplasty carried out in a young adult of 21 with a chronic untreated hip dislocation.
Case Report: We therefore report a 21 year old gendarmerie officer who presented with right hip pain, a shortening limping gaitand a walking time of 10 minutes. He was a victim of a motor vehicle accident with a dash-board mechanism 18 months ago. He sustained a right hip trauma which was treated initially by traditional massage for 6 months. Right hip dislocation was later diagnosedin a hospital and surgical reduction was tried without success. Three months later he presented to us with a right leg length discrepancy of 5cm and atrendelenburg gait. Right gluteus medius muscle power was 3/5. Pelvic x-ray (fig1) shows femoral head ascension, poor head implantation, a coxa magna, a coxavalga and a neo-acetabulum just above an empty paleo-acetabulum. A non-cemented prosthesis with cup size of 48, a femoral head size of 48 and a stem size of 10 was planned,using the MOORE surgical approach which was used for the open reduction attempt (fig2). The per-operatory findings were: a necrotic femoral head (fig3) and a fibrosis-filled.The surgical dissection and implantation into the paleo-acetabulum was difficult and bloody, and required partial sectioning of the gluteus maximus. The piston test, the stability, rotations, and limb lengths were satisfactory. The post-operative findings were unremarkable and the control x-ray was good (fig4). The patient was autonomous at 16 months follow-up without leg length discrepancy.
Conclusion: Chronic untreated traumatic hip dislocations are supposed to be treated with a total hip arthroplastyin order to permit such patients regain active social life. Reduction into the paleo-acetabulum may need partial sectioning or lengthening of the gluteus maximus without influencing the functional outcome of the hip.
Keywords: Chronic non treated hip dislocation, necrosis, coxarthrosis, total hip arthroplasty.
Introduction
The permanent loss of contact between the femoral head and the acetabulum which is not reduced for many weeks constitutes a severe traumatic lesion. The functional outcome of the hip is affected due to the osteo-cartilaginous lesions and necrosis of the femoral head which both lead to coxarthrosis. Concerning these rare forms of hip dislocations, arthroplasty is indicated to help solve the complications which are related to the evolutions of such hips. However, such an arthroplasty can be very difficult because of muscular retractions and the difficulty in finding and working in the paleo-acetabulum. The objective of this work is to report a case of non-cemented total hip arthroplasty carried out in a young adult of 21 with a chronic untreated hip dislocation.
Case report
We therefore report a 21 year old gendarmerie officer who presented with right hip pain, and a walking time of 10 minutes associated with a shortening limping gait. The past history reveals that 18 months before consulting us he was a victim of a motor vehicle accident with a dash-board mechanism. He sustained a right hip trauma which was treated initially by traditional massage for 6 months. Without getting better on this treatment, he consulted in a hospital center where the diagnosis of right hip dislocation was made. A surgical reduction was then tried without success. Three months after the failure of reduction he presented to us with a right leg length discrepancy of 5cm and atrendelenburg gait.
The muscle power of the right gluteus medius was evaluated to be 3/5. The plain AP pelvic x-ray (fig1) shows femoral head ascension, poor head implantation, a coxa magna, a coxavalga, a neo-acetabulum into which the femoral head implants just above an empty paleo-acetabulum. The surgical planning led us to conclude on using the MOORE surgical approach which was earlier used during the first open reduction attempt (fig2). A non-cemented prosthesis with cup size of 48, a femoral head size of 48 and a stem size of 10 was planned. The per-operatory findings were; a necrotic femoral head (fig3) and a paleo-acetabulum filled with fibrosis.The surgical dissection and implantation into the paleo-acetabulum was difficult and bloody, and required partial sectioning of the gluteus maximus. The piston test, the stability, rotations, and limb lengths were satisfactory. The post-operative findings were unremarkable and the control x-ray was good (fig4). The patient was autonomous at 16 months follow-up without leg length discrepancy.
Discussion
Chronic untreated hip dislocations may be missed in the context of multiple injuries [1]. Conversely, our patient turned to empirical treatment followed by an unsuccessful undocumented open reduction which was certainly carried out by less experienced individuals. Femoral head necrosis and coxarthrosis are inevitable in such chronic situations [2, 3]. We opted for a total hip replacement because of the 18 months chronicity of the lesion. With such length of time a continuous traction as recommended by certain authors [4] couldn’t have been effective. This choice of THA permitted us to restore function and alleviate pain in this young adult with high functional demand needed by reason of his profession. We found out that we are not the only ones who used this method [5]. Certain authors recommend the use of prosthesis with double mobility to prevent dislocations caused by muscle retractions [6]. We recommend extreme care not to injure the sciatic nerve during surgery because it is usually beneath the fibrosis near the acetabulum which resulted from anatomical modifications. We equally recommend partial sectioning of the tendon of the gluteus maximus at the level of the quadratusfemoris when longitudinal traction doesn’t permit reduction into the paleo-acetabulum. This procedure didn’t affect the functional outcome of the hip.
Conclusion
Chronic untreated traumatic hip dislocations are supposed to be treated with a total hip arthroplasty in order to permit such patients regain active social life. Reduction into the paleo-acetabulum may need partial sectioning or lengthening of the gluteus maximus without influencing the functional outcome of the hip.
Clinical Message
Chronic untreated hip dislocations are rare lesions which compromise the functioning of the hip due to necrosis of the femoral head and hip osteoarthritis. The presence of a neoacetabulum may lead to the mal positioning of the total hip arthroplasty. It is thus necessary to insert the prosthesis in the paleoacetabulum while considering the presence of muscle retraction.
References
1. D.I. Barnes, H.B. Broude: False aneurysm of the profunda femoral artery complicating the femoral shaft fracture in South African Medical Journal 1985, 67: 824-826.
2. Hamidreza Varastehravan, MD, Hossein Nough, MD, Zahra Ansari, MD* in the paper Management of Iatrogenic Rupture of Profunda Femoris Artery after Femoral Fracture Fixation with Stent Graft Implantation in The Journal of Tehran University Heart Center 2010 42-44.
3. Thomas Aleto MD, Merrill A. Ritter MD, Michael E. Berend MD Case Report Superficial Femoral Artery Injury Resulting From Circlage Wiring During Revision THA Clin Orthop Relat Res (2008) 466:749–753.
4. Winnie Sze-wun Chan, Siu-wah Kong, Kin-wai Sun, Pui-ki Tsang, Hunglit Chow Pseudoaneurysm and intramuscular hematoma after dynamic hip screw fixation for intertrochanteric femoral fracture: a case Report Journal of Orthopaedic Surgery 2010;18(2):244-7.
| How to Cite this Article: H Eone, JE Bayiha, JR Nyekel, B Ngo Nonga , J Bahebeck. Paleoacetabular Total Hip Arthroplasty Indicated For A Chronic Non Treated Hip Dislocation. International Journal of Surgical Cases 2015 Oct-Dec;1(2): 3-4. |
